Provider Demographics
NPI:1992336556
Name:MARTIN, JESSICA ANNE (MSW, LSWAIC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSW, LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12112 E ALKI AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-5189
Mailing Address - Country:US
Mailing Address - Phone:509-714-2143
Mailing Address - Fax:
Practice Address - Street 1:12112 E ALKI AVE APT 11
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-5189
Practice Address - Country:US
Practice Address - Phone:509-714-2143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WA611311321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician